Utilization Management Specialist at SmarterDx

, , United States -

Full Time

Start Date

Immediate

Expiry Date

14 Apr, 26

Salary

260000.0

Posted On

14 Jan, 26

Experience

10 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization Management, Clinical Judgment, Medical Necessity Review, Level of Care Decisions, CMS Guidelines, InterQual, MCG, EMR Workflows, AI Prompt Engineering, Peer-to-Peer Reviews, Documentation Quality, Clinical Workflows, Healthcare Technology, Physician Advisory Work, Denial Management, Patient Tracking

Industry

Hospitals and Health Care

Description

SmarterDx, a Smarter Technologies company, builds clinical AI that is transforming how hospitals translate care into payment. Founded by physicians in 2020, our platform connects clinical context with revenue intelligence, helping health systems recover millions in missed revenue, improve quality scores, and appeal every denial. Become a Smartian and help optimize the way the healthcare system works for everyone. Learn more at smarterdx.com/careers. Utilization Management Specialist Role The Utilization Management (UM) Specialist will play a critical role in SmarterDx’s expansion into the Utilization Management space. This role will work closely with Product and Data Science teams to apply real-world physician judgment to the development of clinical logic, workflows, and evidence interpretation that support accurate, defensible level-of-care decisions. **This role is fully remote within the US** What You’ll Do Review and refine AI-generated clinical summaries and indicators related to medical necessity, level of care, and patient status, ensuring outputs reflect real-world physician reasoning and defensibility Collaborate with Product and Data Science teams to define and validate clinical logic that surfaces relevant evidence and highlights potential status misalignment Translate clinical knowledge into prompts and guidelines for large language models Apply a physician advisor perspective to help model clinical gray areas where documentation quality, acuity, and trajectory matter most Support the design of UM workflows that assist nurses and physician advisors in efficiently reviewing cases without directing clinical decisions Translate utilization review standards, regulatory guidance, and clinical judgment into clear product requirements and clinical guidelines for level of care determinations Serve as a clinical subject matter expert for level of care determinations, escalation pathways, and payer-facing documentation expectations What You Bring Physician background with experience in utilization management, physician advisory work, or medical necessity review in an acute care setting Strong understanding of how level-of-care decisions are evaluated, escalated, and defended over the course of a hospital stay Deep knowledge of CMS 2-Midnight Rule, Condition Code 44, OC72, and related inpatient/outpatient guidelines. Familiarity with tools such as InterQual® or MCG® and EMR-based workflows for utilization review and patient tracking. Prior experience, or strong interest, in advising healthcare technology companies and building systems to support real-time utilization review. Comfort operating in clinical gray areas where criteria are not definitive and documentation quality materially impacts outcomes Must Haves MD or DO Direct experience performing physician advisory work, or medical necessity determinations Direct experience participating in peer-to-peer reviews with payers Direct experience overseeing care for hospitalized patients Ability to clearly articulate clinical reasoning and translate it into structured logic Comfort working in a non-clinical, product-focused role Nice To Haves Prior experience with AI prompt engineering Previous advising or consulting experience with healthcare technology companies Experience working with or overseeing physician advisor teams or UM teams Familiarity with denial management related to medical necessity or level of care Compensation $230k-$260k base + benefits #LI-Remote Benefits Medical, Dental & Vision – Comprehensive plans with leading insurance providers, covering 75% of your premiums, depending on the plan. Paid Parental Leave – Generous paid leave to support families through birth or adoption: Up to 12 weeks for parents. Remote-First Team – Work from anywhere in the U.S. Unlimited PTO & 10 Holidays – So you can relax and recharge. 401(k) with Traditional & Roth Options – Tax-advantaged retirement savings through Fidelity with a 4% match. Minimal Bureaucracy – A fast-moving, high-impact environment where you can focus on what matters. Incredible Teammates! – Work alongside smart, supportive, and mission-driven colleagues.

Responsibilities

The Utilization Management Specialist will review and refine AI-generated clinical summaries and collaborate with Product and Data Science teams to develop clinical logic. They will also serve as a clinical subject matter expert for level of care determinations and support the design of UM workflows.